Review articles

By Ms. Erma Qazi , Mr. Muhammed Siddiqui
Corresponding Author Ms. Erma Qazi
Liverpool, - United Kingdom
Submitting Author Mr. Muhammed R Siddiqui
Other Authors Mr. Muhammed Siddiqui
Mayday Hospital, 23 Malvern Road - United Kingdom TN24 8HX


General Practice;

Qazi E, Siddiqui M. How have the Changes to the Out of Hours (OOH) Primary Care provision brought about by the 2004 GP contract affected patient safety?. WebmedCentral GENERAL PRACTICE 2012;3(5):WMC00614
doi: 10.9754/journal.wmc.2012.00614

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 05 May 2012 10:33:24 PM GMT
Published on: 07 May 2012 10:53:48 PM GMT


The GP contract was changed in 2004. One of these major changes was the Out of Hours system, where GPs had the option to opt out of providing Out of Hours care to patients and shifted this Out of Hours Care responsibility to PCTs. A new model of Out of Hours healthcare was proposed by the Carson review, this was supposed to provide a fast, fair and convenient access to health care.

However, this new Out of Hours health care system may have caused an unfortunate death of a woman named Penny Campbell due to inadequate communication of Out of Hours Primary Care providers. 

Therefore this review researches into: Have the changes to Out of Hours (OOH) Primary Care provision brought about by the 2004 GP contract affected communication between OOH providers, and the patients’ registered GP and the affect this has on the continuity of care?

Studies were searched through many electronic databases such as Scopus, PubMed and Medline (OVID) and then selected for the review by applying the inclusion/ exclusion criteria.  After the studies were critically appraised and discussed the conclusion drawn was that the communication within Out of Hours services and information transferred to Patients’ registered GPs has seen to be inadequate in both Pre- contract and Post contract changes of Out Of Hours Primary Care provision and therefore there has been a decrease in the quality of continuity of care for patients. 


The new GP contract

In June 2003 GPs around UK voted to accept the changes made in the GP contract, for the changes made in delivering healthcare and general medical services. These changes in the GP contract came into effect on 1st April 2004 (1). 

The new GP contract was formed and implemented so that there could be an improvement in GP work lifestyles, fairer funding and availability of local health care provision, improvement of management of chronic diseases and improvement of organisational standards (1).

There were many major changes involved in the new GP contract to fulfil these expectations, most noticeably, the change in the Out Of Hours agreement in the contract.

Out of Hours

In the UK, Out of Hours is defined as the period of time between 18.30 and 08.00 on weekdays, weekends and bank holidays (2).

Changes in the Out of Hours services in the 2004 GP contract

Before the 2004 contract changes GPs were obliged to provide urgent Out of Hours care, but had the power to delegate some of their work to GP co-operatives or the private sector because of arrangements made in the mid-1990’s, so that GPs can co-operate more and focus more on premises-based care (3).

The post-contract changes from 1st April 2004 gave GPs the option to opt out of Out of Hours care and shift this responsibility to PCT’s, where PCTs are then required to take full responsibility to provide effective Out- of Hours Care (4) with the cost of £6000 per year, if GPs do decide to opt out (3).

This new system promotes the integration of GP co-operatives, private firms, independent doctors and triage nurses, competing for the contract to provide this service (5).

Practices that decide not to opt out of providing Out of Hours services, GP Practices are required to provide Out of Hours services to their patients (1).

The changes in the out of hours occurred due to the following reasons:

• Due to the various health-care reform of primary care services and the need to improve the quality of primary care provision caused an increase in workload and pressure for GPs, which caused an “anticipated retirement and  the shortfall in GP recruitment” this thus created a “workforce crisis within the profession” (6).

•  Anecdotal evidence suggested that the pre-contract Out of Hours changes were unequal in providing quality of care and varied by different providers and geographical areas(3), this was further reinforced by an increasing number of complaints and negative reports in the media and this led the Health Service Commissioner to raise concerns about Out-of Hours services with the Department in 2000(3).

Because of these negative occurrences, The Department of Health concluded that the current Out of Hours service (pre-contract changes in 2004) was unsustainable(3) and on 2nd March 2000, the Minister of State Health (Mr John Beacon) had announced to do a review of the Out of Hours service across England (7).  The aim of this review was to “assure quality” and to “improve recommendations” to improve services(3).

The leading review that addressed the issues adequately was the Carson review, which gave a “critical verdict of the issues regarding quality, safety and effectiveness” (8). However other reports too provided a background for the current Out-of Hours service. One of them was the NHS Plan.  Whilst the NHS Plan was published in 2000, Carson review was still under progress, due to the early publication of the NHS Plan, this helped built Carson’s review preliminary findings(3).  Another report which helped clarify The Department’s policy objectives for emergency services, operating in the Out-of Hours period, was the 2001 report Reforming Emergency Care(3).

Carson Review

The Carson Review was published by a team on October 2000; the leader of the review team was Dr. David Carson(5). This review made 22 recommendations, which were accepted in full and implemented by the Department of Health(3).

The Carson Review work was based on the following principles: on meeting patients’ needs and perspectives rather than the GPs’ needs and perspectives, for patients’ to have equal high quality care on out-of-hours services regardless of their geographical location.  To meet patients’ urgent needs, that cannot be safely deferred until the patient’s own GP practice is open.  Family doctor services will continue to be based on the patient list system, with GPs retaining 24 hour responsibility for their list(5).

By putting all these fundamental principles in mind, the Carson Report proposes an integrated flexible model for the Out-of Hours provision which proposes a delivery of high quality of care to patients around the country (9).

This Model looks from the patient perspective. The most important features of this model are the fast and rapid contact with primary care services. This should just involve a single call from the patient during Out of Hours, where the patient would get in contact with NHS direct. The information which the patient gives would be recorded and this information from the patient would be triaged and directed to the appropriate services according to the patient’s needs and health. However, in rare circumstances where the symptoms of a patient seem severe and urgent medical care is required, an ambulance would be called(5).

Patients, who receive palliative care, would not be triaged and would be directly passed to services which would meet their needs(5).

Recently there has been a rise in a number of complaints about the Out Of Hours system. The MDU reported: “…. just over 200 GP complaints involving out of hours care last year, accounting for around seven per cent of all GP complaints notified. This represents an increase in complaints from 2002 (pre-contract changes) when MDU GP members notified 120 complaints relating to out of hours care” (10).

These complaints were mostly about the communication between the Out- of Hours service providers and the patients’ doctors (11).

When a patient uses the Out- of Hours service, another GP or another health professional and not their usual GP are providing care to the patient and they may not have access to medical records. This means that valuable information about the patients’ medical history is unknown and GPs are basing their clinical decisions on patients’ recall of medication history(11).  There is sometimes no sharing of information between out-of hours and therefore this leads to no continuity of care, therefore every case is considered as a new case and this may lead to an inaccurate diagnosis(5).

Unfortunately due to the lack of communication between the Out- of Hours service providers and their patients’ doctors and the lack of continuity of care, this resulted in a death of a 41 year old mother and journalist named Penny Campbell who contracted Septicaemia from a small routine operation, this led to multiple organ failures and eventually died two years later in March 2005 (12). 

Ms Campbell was consulted with eight different doctors under the new Out of Hours system, each doctor diagnosed her with different illnesses, because each time she contacted the Out-of Hours service, her case was treated as a new case and there were no information shared between the doctors she consulted, “each of whom failed to diagnose her with Septicaemia”(5).

Due to the case of Ms Campbell and the series of complaints, this review will assess the communication between Out- of Hours providers and patients registered GP and the continuity of care of the post-contract changes of the OOH health care model.

The aim of this article is to assess whether the changes to Out of Hours (OOH) Primary Care provision brought about by the 2004 GP contract affected communication between OOH providers and the patients’ registered GP, and what effect this has on the continuity of care?


For searching information, mainly online searches were used.  Multiple databases and search engines were used, due to the lack of relevant articles on one database.  Databases that were used for this review was Medline (via OVID), EBSCO, SCOPUS and PubMed.

Articles were selected which assesses the aim. Both pre-contract Out- of Hours changes and post contract Out- of Hours changes would be assessed.  Pre-contract studies would be selected to compare to see if there is a significant change of the Post-contract changes of continuity of care and communication between Out-of Hours and patient’s registered GP, if any. After selecting studies; the studies would be critically appraised and the studies’ results would be reported.

The following criteria would be assessed in each article, to see which article is most suitable and relevant to this review:


Overall the results suggest that continuity of care of patients between Out Of Hours services and patients’ registered GP’s have been of poor quality due to an inadequate communication within the Out of Hours Primary Care providers and with the patients’ registered GP.

Mainly all of the studies suggested that poor communication was due to the reason of an inadequate transferring of patient’s information and lack of information gathered within the Out of Hours Primary care and inadequate information transferred from and to the patient’s registered GP in both pre contact and post contract changes of Out of Hours Primary Care. 

Communication within the Out of Hours Services

As concluded by Burt et al study (2004) (Table 2) about communication within Out of Hours primary care services (before the changes made in OOH primary care): “……Continuity of care within co-operatives was frequently threatened by a lack of information about previous contacts to the service by a patient”(15). Which suggest that even before changes were made in the Out-of Hours system there were still issues of inadequate amount of information that affected continuity of care within GP co-operatives.

Similarly Taubert et al study (Table 5) suggested that there is a lack of information exchange (18).

From the deduction of these two results; triage times have increased in Out of Hours services.  This deduction is reinforced by Richards et al study (2010) (Table 3).  Where the results had shown that in the Post contract OOH changes, the triage times had significantly increased.  This can be fatal to a patient’s safety because some patients may need urgent medical need.

Kinnersley et al study (2010) (Table 4) results suggested that communication with the patient in the Out of Hours providers was dissatisfactory as well (17).  This can affect the patients’ continuity of care, since if clear information is not given, the patient does not know on how to approach medical services to aid their health needs and therefore this can cause a detrimental effect to the patient’s health.

Communication between Out of Hours Providers and patients’ registered GP

 Basing from Burt et al (2004) study’s conclusion; pre-contract changes of Out Of Hours care, GP co-operatives sometimes did not make patients’ registered GP aware about the contacts which the patient had with the Out of Hours GP cooperatives.

 Comparing this with the post- Out of Hours GP contract changes many of the studies’ results suggested that there should be an improvement with the communication between Out of Hours care and In-Hours care.  Richards et al study results’ (a post- contract changes in Out of Hours study) has shown that, ‘special messages’ sent by the ‘out-of-hours clinician had decreased’(8) and that triage time has increased and ‘adverse changes to triage time were observed’(8).

These studies show that even though some patients’ information (during the pre- contract Out of Hours changes, time period) were not sent to the in-hours GP from the GP co-operatives, however this has declined after the changes to Out of Hours contract changes in 2004.

This could be because most GPs do not think it is obligatory to pass patients’ information of patients, to Out-Of hours GPs as deduced by Taubert et al study (2010) (Table 5), where only two GPs out of nine had stated that it is compulsory to keep accurate notes and to pass information about their patient from in-hours care to Out- of Hours care(18).

Personal Opinion of the current Out of Hours health care model and personal opinion of the improvement of the current health care model

The positive aspects of the current Out of Hours model is that it has many services and health professionals available for the patients’ health needs during the Out of Hours period, and all of them are available from just one phone call as highlighted by the Carson’s integrated Model of Out of Hours Care(5).  It makes full use of the range of services and health professionals, instead of just the patients’ registered GP solely providing care.

There are many services for good continuity of care for patients using Out of Hours services.  However, unfortunately these services of continuity of care are being lowered because of poor quality of information within the Out of Hours system.

Improvement of the current health care model in terms of communication, for providing adequate continuity of care

Communication should be improved within the Out of Hours system and with patients’ registered GPs.

This could be done by enforcing an obligatory law of Out of Hours Primary Care Services to obtain patients’ records from patients’ in- hours registered GPs, when patients use the Out- of Hours services.

Keeping an accurate health record of each and every patient, when the patient has received care of any type of health service should be made obligatory as well.  This record should be made accessible for both in- hours GP and Out- of Hours GP, but these records should be accessible quickly and efficiently, so to decrease triage times.  The most efficient way of recording patients’ information would be entering information electronically and sending patients’ information to and from in-hours GP care to Out of Hours care.

Since NHS Direct is the first point of contact with patients to accessing other health care according to their health needs.  Data management of patients’ records could be set alongside with the NHS direct.

This data management can have previous information about the patients’ records, sent by the patients’ registered GPs (from in- hours care) and when patients are directed to a particular service/ services, staffs that are responsible for data management can send this information by an electronic system to a particular service/s and when that service has finished with the care of the patient, this information can be sent to the data management service to be recorded.

If a patient then seeks consultation to their registered GP after the Out of Hours care.  Information about Out of Hours care the patient received could then be sent to the patients’ registered GP.  This can improve the communication between Out- of Hours care and in- hours care.


In general the communication within Out of Hours services and information transferred to Patients’ registered GPs has seen to be inadequate in both Pre- contract and Post contract changes of Out Of Hours Primary Care provision and therefore there has been a decrease in the quality of continuity of care for patients. 

During the Out- of Hours services there has been a decrease in sending patient information to in-hours GPs and an increase in triage times, which has a negative impact on patient safety.


1. Department of Health, Social Services and Public Health. GP contracts. (accessed 31/01/2011)
2. NHS Confederation, British Medical Association. The new general medical services contract. London: The NHS Confederation; 2003.
3. National Audit Office. The Provision of Out-of Hours Care in England. London: TSO (The stationary Office); 2006. Report no: HC 1041.
4. The New GMS contract explained. Focus on…. Out of Hours. (accessed 06/06/2011).
5. Thompsons Solicitors.  GP Out Of Hours Service – Fatal Flaws? (accessed 06/02/2011)
6. Peter Spurgeon, Carolyn Hicks, Stephen Field, Fred Barwell. The new GMS contract: impact and implications for managing the changes. Health Services Management Research 2005;18:75-85
7. Carson D. Raising Standards for Patients. New Partnerships in Out-of Hours care., 2000.
8. Richards SH, Winder R, Seamark D, Seamark C, Ewings P, Barwick A, et al. Accessing out-of-hours care following implementation of the GMS contract: an observational study. Br J Gen Pract 2008;58(550):331-8
9. Cannock Chase Council's Health Scrutiny Panel. Review of GP Out of Hours Service. 2004
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11. Management in Practice.  Communication key to avoiding out of hours complaints (Publication Date: Monday 11th June 2007). ints? (accessed 07/02/2011)
12.BBC News.  Brown calls for better GP cover (last updated: 25 May 2007) (accessed 07/07/2011)
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14. The British Journal of General Practice, Leading Primary Care Research (accessed 04/02/2011)
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17. Kinnersley P, Egbunike JN, Kelly MJ, Hood K, Owen-Jones E, Button LA, et al. The need to improve the interface between in-hours and out-of-hours GP care, and between out-of-hours care and self-care. Family Practice 2010;27(6):664-72
18. Taubert M, Nelson A. Out-of-hours GPs and palliative care-a qualitative study exploring information exchange and communication issues. BMC Palliat Care 2010;9:18.

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